AP Testing – Risk & Insurance Associates

Step 1 of 7

Name *

First

Middle

Last

SSN *

Email *

DOB *//

Gender *

Job Title *

Resident State

Insurance License #:

Are you currently a registered representative with FINRA (IE: hold series exams)? *

Business Phone *

Mobile *

Fax

Residential Address (NO P.O. Boxes): *

Address Line 1

City

State

Zip Code

When did you start living at this address: *//

Business Address (NO P.O. Boxes): *

Address Line 1

City

State

Zip Code

What is your Preferred Mailing Address? *

Residential
Business

Who referred you to our brokerage platform?

Direct Deposit - Electronic Fund Transfers (EFT)

Individual Contracting? Account must be under Your Name. OR Agency Contracting? Account must be under the Agency Name.

Account Owner Name *

Transit/Routing # *

Account # *

Account Type *

Checking
Savings

Financial Institution Name *

Bank Address

Address Line 1

City

State

Zip Code

By signing below, I herby authorize the Company to initiate credit entries and, if necessary, adjustments for credit entries in error to the checking and/or savings account indicated on this form. This authority is to remain in full effect until the company has received written notification from me of its termination. I understand that this authorization is subject to the terms of any agent or representative contract, commission agreement, or loan agreement that I may have now, or in the future, with the Company. *

Date *

Please attach a copy of a VOIDED CHECK or a LETTER FROM YOUR BANK on Bank letterhead confirming Account Name, Account #, & Transit/Routing #. *

Click or drag a file to this area to upload.

DIRECT DEPOSIT AGREEMENT & AGREEMENT TO REPAY COMMISSIONS PAID TO

Name *

First

Last

BY Risk & Insurance Associates and affiliate companies (Barnum Financial Group, LLC & Barnum Benefit Advisors, LLC)

SSN/TIN *

I (the Signature Authorizer above) hereby authorize Risk & Insurance Associates and affiliate companies to initiate automatic deposits to my account listed on the Direct Deposit – Electronic Funds Transfers (EFT) form and agrees to repay to Risk & Insurance Associates and affiliate companies any and all commission paid to me by Risk & Insurance Associates and affiliate companies in the event the policy is returned, there is a reduction in face amount, there is a policy recission, a charge back by the insurance carrier for any reason or an overpayment error occurs. Further, I agree not to hold Risk and Insurance Associates or affiliate companies responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account. *

Date *

Phone

Legal Questions for Contracting and Appointment Requests

Direct Deposit - Electronic Fund Transfers (EFT)

DIRECT DEPOSIT AGREEMENT & AGREEMENT TO REPAY COMMISSIONS PAID TO

Errors & Omissions Coverage (E&O)